Multiple-dose Insulin Research Articles

Management of Type 2 Diabetes – Methods for Addition of Prandial to Basal Insulin

As glycaemic control deteriorates with the progression of type 2 diabetes, treatment guidelines advocate starting basal insulin therapy, and then progressing to a basal–bolus regimen as needed. Nevertheless, although timely intensification of therapy is important to minimise the risk of diabetic complications, considerable clinical inertia exists, not only in the initiation of insulin but also in the progression to multiple-dose insulin regimens. One barrier has been the lack of guidance about how to make the transition from basal-only to basal–bolus insulin therapy. In this review, we discuss how data from the recent FullSTEP study, along with other randomised studies, will help to bridge this gap. Prandial boluses can be added to basal insulin in a stepwise manner, using a straightforward, patient-led dose titration approach and simple estimation of which meal to add the initial prandial bolus to. Reducing the complexity of progression to multiple-dose insulin regimens and empowering patients will lessen the burden on clinicians, improve treatment satisfaction and facilitate timely implementation of treatment guidelines.

Psychometric analysis of the Spanish and Catalan versions of the Diabetes Self-Care Inventory-Revised version questionnaire

BackgroundThe purpose of this study was to validate the Spanish and Catalan versions of the Diabetes Self-Care Inventory-Revised Version (SCI-R) questionnaire to assess the degree of adherence to self-care among adults with diabetes.MethodsWe validated the Spanish and Catalan translation from, and back translation to, English and cultural adaptation of the SCI-R in type 1 diabetes patients on multiple insulin doses or continuous subcutaneous insulin infusion and in type 2 diabetes patients on oral agents and/or insulin. Internal reliability, structural validity, and external validity (correlation with glycated hemoglobin) were evaluated. Responsiveness to change was assessed in patients 1 year after onset of type 1 diabetes and following a structured education program.ResultsThe SCI-R presented good internal reliability Cronbach’s α: 0.75, test-retest reliability (r = 0.82) and structural validity (r > 0.40). The external validity was also good; the SCI-R correlated with HbA1c in patients with type 1 diabetes on multiple insulin doses (r = −0.50) or continuous subcutaneous insulin infusion (r = −0.66) and in patients with type 2 diabetes on multiple insulin doses (r = −0.62). However, it was not satisfactory in patients on oral agents (r = −0.20) and/or bedtime insulin (r = −0.35). Responsiveness to change was analyzed in 54 patients (age 27.3±7.4 years, 26% men, HbA1c 6.8% ±1.1%); the SCI-R score was 72.3% ±13.7% and correlated negatively with glycated hemoglobin (r = −0.42) and 3 scales of the Diabetes Quality of Life questionnaire (lower score indicating better perception): Impact (r = −0.37), Social Worry (r = −0.36) and Diabetes Worry (r = −0.38), all at P < 0.05.ConclusionThe Spanish and Catalan versions of the SCI-R questionnaire show good psychometric properties and both could be considered as useful tools for evaluating self-care behavior in patients with type 1 or type 2 diabetes. However, there are still some subgroups of patients with type 2 diabetes in which the validity of this questionnaire needs further evaluation.

Evidence-based clinical use of insulin premixtures.

Brazil is expected to have 19.6 million patients with diabetes by the year 2030. A key concept in the treatment of type 2 diabetes mellitus (T2DM) is establishing individualized glycemic goals based on each patient’s clinical characteristics, which impact the choice of antihyperglycemic therapy. Targets for glycemic control, including fasting blood glucose, postprandial blood glucose, and glycated hemoglobin (A1C), are often not reached solely with antihyperglycemic therapy, and insulin therapy is often required. Basal insulin is considered an initial strategy; however, premixed insulins are convenient and are equally or more effective, especially for patients who require both basal and prandial control but desire a more simplified strategy involving fewer daily injections than a basal-bolus regimen. Most physicians are reluctant to transition patients to insulin treatment due to inappropriate assumptions and insufficient information. We conducted a nonsystematic review in PubMed and identified the most relevant and recently published articles that compared the use of premixed insulin versus basal insulin analogues used alone or in combination with rapid-acting insulin analogues before meals in patients with T2DM. These studies suggest that premixed insulin analogues are equally or more effective in reducing A1C compared to basal insulin analogues alone in spite of the small increase in the risk of nonsevere hypoglycemic events and nonclinically significant weight gain. Premixed insulin analogues can be used in insulin-naïve patients, in patients already on basal insulin therapy, and those using basal-bolus therapy who are noncompliant with blood glucose self-monitoring and titration of multiple insulin doses. We additionally provide practical aspects related to titration for the specific premixed insulin analogue formulations commercially available in Brazil.

Simultaneous Use of Two External Subcutaneous Pumps Delivering Insulin and SYMLIN: Use of a Double-Pump System

The combination of insulin and an amylin mimetic is an option for diabetes treatment.1,2 The effectiveness of this modality has been established, but there is a limited amount of literature regarding the use of this combined treatment via continuous subcutaneous infusion by external pumps. A short 16-week trial of 10 patients studied the pharmacokinetics of pramlintide (SYMLIN®, Amylin Pharmaceuticals, LLC, San Diego, CA) in continuous subcutaneous infusion and found this modality to be safe and well tolerated.3 Treatment was initiated in a small study of 10 subjects (7 females and 3 males) with age range 24-69 years. There were 5 patients with type 1 diabetes and 5 with type 2 diabetes (duration of diabetes: 15-38 years). Patients were switched from conventional multiple-dose insulin injection therapy or oral hypoglycemic agents to the combination of insulin and SYMLIN via continuous subcutaneous infusion using two external pumps simultaneously. Treatment was continued over a period of 1-5 years. Hemoglobin A1c (HbA1c), total daily insulin, total daily SYMLIN, weight, and blood glucose levels were measured, with follow-up ranging from 1-5 years. Patients using the double-pump system showed an average reduction in HbA1c from 8.3% to 6.9%. Total daily insulin was reduced from an average of 147 to 96 units per day. SYMLIN dosages increased from an average of 35 units per day to 50 units per day (Figure 1). Weight reduction was noted, with an initial average of 132 to 500 lb, decreasing to 110 to 360 lb. Figure 1 Insulin dosage vs SYMLIN dosage over duration of study. Amylin conversion of units to micrograms: 1 unit = 6 μg. Patients were treated with basal SYMLIN 0.5-2.5 unit/h (3-15 μg). Meal bolus was 2.5-10 units (15-60 μg). All patients completed a satisfaction survey and expressed satisfaction with the treatment regimen but indicated their preference for a dual or multichamber device. They also noted that they would not return to conventional SYMLIN injections if given the choice. We conclude that continuous infusion of insulin and SYMLIN via a pump system is a viable and effective therapeutic option. In this small observational study, all patients showed improvement in metabolic and weight control over a period of 1-5 years. Further studies with a larger population and a control group are needed to empower these results.

Effects of Type 2 Diabetes and Insulin on Whole-Body, Splanchnic, and Leg Protein Metabolism

Type 2 diabetes (T2D) is characterized by insulin resistance to glucose metabolism. Most studies suggest that protein metabolism is unaffected by T2D, but regional protein metabolism and response to multiple doses of insulin have not been examined. Our objective was to determine whether insulin regulation of splanchnic and leg protein metabolism are affected by T2D during hyperglycemia and graded insulin levels. We conducted a cross-sectional study at an academic medical center. T2D and non-T2D adults were matched for age (62 yr) and body mass index (30 kg/m(2)). Glucose was maintained at approximately 9 mmol/liter while insulin was infused at three progressively higher rates, achieving circulating concentrations of approximately 150, 350, and 700 pmol/liter, respectively. Protein kinetics were measured using labeled phenylalanine (Phe) and tyrosine (Tyr). Whole-body protein breakdown and synthesis rates were higher in T2D but declined with increasing insulin in both groups. Leg Phe and Tyr appearance and disappearance and estimates of protein breakdown and synthesis, respectively, were higher in T2D but did not decline significantly with insulin, resulting in similar net balance between groups. Splanchnic response to insulin was blunted in T2D, shown by a smaller reduction in rates of disappearance and net balance of Phe and Tyr as insulin increased. Splanchnic conversion of Phe to Tyr was lower in T2D and less sensitive to insulin, whereas nonsplanchnic Phe to Tyr tended to be higher in T2D. T2D results in higher whole-body, splanchnic, and leg protein turnover and blunts the insulin-mediated suppression of splanchnic protein anabolism under hyperglycemic, hyperinsulinemic conditions.

The role of continuous subcutaneous insulin infusion therapy in patients with diabetic gastroparesis

To describe the effectiveness of continuous subcutaneous insulin infusion (CSII) in patients with symptomatic diabetic gastroparesis and unstable glycaemic control. Data from 26 patients with symptomatic diabetic gastroparesis and unstable glycaemic control using multiple-dose insulin (MDI) regimens, and subsequently managed with CSII, were analysed. Following initiation of CSII, the median length of inpatient bed days associated with hospital admissions related to gastroparesis and glycaemic instability was reduced from 8.5 (range 0-144) days patient( -1) year( -1) prior to CSII to 0 (range 0-15) days patient( -1) year( -1). The median HbA(1c) reduction with CSII was 1.8% (22 mmol/mol; p < 0.05). The median capillary blood glucose (CBG) with CSII was significantly lower than with MDI: 7.7 mmol/l (range 3.8-15.4 mmol/l) vs 9.8 mmol/l (range 2.3-27 mmol/l), respectively, p < 0.001. Glycaemic variability with CSII was significantly reduced compared with MDI: CBG CV 0.37 vs CV 0.53, respectively, p < 0.001. CSII therapy in patients with diabetic gastroparesis results in significant improvement in glycaemic control and reductions in glycaemic variability and number of hospital inpatient bed days.

Monitorización continua de glucosa en tiempo real: imprescindible su uso combinado con infusión continua de insulina

Baseline-bolus insulin therapy administered using continuous insulin infusions (insulin pumps) is currently the most effective and safe treatment to achieve good metabolic control in patients with type 1 diabetes mellitus, and is experiencing dramatic progress in the last few years with the launching of increasingly more intelligent devices, with programs with specific characteristics, including aids for the administration of a bolus, active insulin functions, establishing targets, etc. For these reasons, the greatest technological advance in intensive diabetes therapy has been the development of real-time continuous glucose monitoring and their integration with insulin pumps. Their clinical impact has been demonstrated, with a major reduction in the glycosylated haemoglobin, without increasing the risk of hypoglycaemia compared to treatment with multiple dose insulin regimes or subcutaneous insulin only infusion systems. Different clinical studies support the evidence for recommending the use of therapies with an insulin pump integrated with continuous glucose monitoring, and will be critically reviewed in the present article.

Insulin pump therapy: closing the inequality gap

110 Nurse Prescribing 2011 Vol 9 No 3 adapted accordingly. Mimicking the natural production of insulin is complex, and the way insulin is delivered through insulin pump therapy is closer to this natural phenomenon than multiple-dose insulin injection therapy. Pumps can help when: regulation is not sufficient with multiple-dose insulin injection therapy; glucose levels are unpredictable; the patient experiences severe hypoglycaemia, or even fits. Experience has shown that the use of the pump in the latter case led to the patient no longer experiencing fits or severe hypoglycaemia.

Sustained Efficacy of Continuous Subcutaneous Insulin Infusion in Type 1 Diabetes Subjects with Recurrent Non-Severe and Severe Hypoglycemia and Hypoglycemia Unawareness: A Pilot Study

This study evaluated the effect of CSII on hypoglycemia awareness and on glucose profile in type 1 diabetes (T1D) subjects with repeated non-severe or severe hypoglycemia (NS or SH, respectively). We included subjects (1) older than 18 years, (2) with T1D duration of >5 years, (3) on multiple doses of insulin, and (4) without micro- or macrovascular complications and more than four NS events per week (in the last 8 weeks) and more than two SH events (in the last 2 years). NS/SH episodes and hypoglycemia awareness were evaluated. A 72-h continuous glucose monitoring (CGM) was performed before continuous subcutaneous insulin infusion (CSII). A hypoglycemia-induced test was used to evaluate each patient's symptoms in euglycemia/hypoglycemia. Quality of life (QoL) was also evaluated. After 6, 12, and 24 months, all the subjects were reevaluated. Twenty subjects were included (34.0 +/- 7.5 years old, 12 women, A1c 6.7 +/- 1.1%, 16.2 +/- 6.6 years of diabetes' duration). At baseline, 19 out of 20 subjects displayed hypoglycemia unawareness, which diminished significantly during the follow-up (3 out of 20). NH episodes per week diminished from 5.40 +/- 2.09 at baseline to 2.75 +/- 1.74 at the end of the follow-up (P < 0.001). SH episodes fell from 1.25 +/- 0.44 per subject-year to 0.05 +/- 0.22 after 24 months (P < 0.001). Hemoglobin A1c remained unaltered. With CGM, the percentage of values within 70-180 mg/dL increased (53.2 +/- 11.0% to 60.3 +/- 17.1%, P = 0.13), and the percentage of values <70 mg/dL decreased (13.7 +/- 9.4% to 9.1 +/- 5.2%, P = 0.07), after 24 months. Mean amplitude of glycemic excursions diminished after 24 months of CSII (136 +/- 28 mg/dL to 115 +/- 19 mg/dL; P < 0.02). An improvement in all the aspects of QoL was observed. The basal alteration in symptom response to an induced hypoglycemia improved after 24 months of initiating CSII leading to a response indistiguishable from that observed in a control group of subjects with T1D without repeated NH and SH. CSII prevents hypoglycemic episodes, improves hypoglycemia awareness, and ameliorates glycemic profile in T1D subjects with repeated NS/SH. Its use is also associated with an improvement in diabetes QoL.

Utilization of an abbreviated diabetes impact management scale to assess change in subjective disability during a trial of pulsatile insulin delivery demonstrates benefit

A prospective interventional study of pulsatile intravenous insulin infusion therapy has demonstrated reduction of left ventricular mass and blunting of progression of diabetic nephropathy. We anticipated that improvements in objective parameters would be associated with similar improvement measurable by the self-administered Diabetes Impact Management Scale (DIMS). The DIMS was administered at baseline and 12 months for 19 participants randomized to receive either standard insulin treatment of 3 to 4 injections of insulin daily or insulin treatment plus an additional day per week of 3 intravenous pulses over an 8-hour period. For standard vs pulsed intravenous insulin therapy, mean baseline scores were similar for the 12 total questions as well as the groups of 7 questions with emotional content and 5 with physical (neurologic) content. Mean study group scores at 1 year and changes over 1 year were not significantly different for the 7 questions with emotional content ( P = .3143, .7574). Score results for the 5 questions related to neurologic status at 1 year and changes over 1 year were significantly different between patients with standard and with pulsed insulin therapy ( P = .0144, 0.0004). Pulsatile intravenous insulin, when added to standard multiple-dose insulin therapy, was demonstrated to improve subjective perception of neurologic disability on repeated use of an abbreviated form of the DIMS.

TYPE 1 DIABETES IN PREGNANCY; INFLUENCES ON MOTHER AND FETUS

Type 1 diabetes complicates around 1 in 200 to 300 pregnancies in the United Kingdom. Historically maternal type 1 diabetes carried very high risks for mother and child. Introduction of insulin led to an immediate, marked decline in the previously very high rates of maternal mortality; in contrast an improvement in perinatal outcomes occurred more slowly but was nevertheless dramatic. This is strikingly demonstrated by the temporal decline in perinatal mortality in offspring of mothers with type 1 diabetes which was virtually universal before use of insulin in the 1920's, likely remained in excess of 20% even in the 1960's and fell to under 4% by the 1990's. The reasons for this more gradual improvement in perinatal outcomes cannot be defined with precision but will have been influenced by improved glycaemic management with use of intensive, multiple dose insulin treatment and home glucose monitoring; improvements in obstetric and neonatal management, and better management of complications of diabetes before and during pregnancy. In 1989 the St Vincent declaration proposed that pregnancy outcomes in women with type 1 diabetes should approximate those of the non-diabetic population. While the long term improvements in fetal outcomes have been dramatic, contemporary surveys confirm a persistent doubling or more of rates of congenital anomaly and a three to four fold increase in perinatal mortality in the UK and other European countries which will require further clinical innovation to overcome.

Continuous subcutaneous insulin infusion and multiple dose insulin injections in Type 1 diabetic pregnant women: a case-control study

The aim of this study was to evaluate the effects of continuous subcutaneous insulin infusion (CSII) on glycemic control and pregnancy outcomes in Type 1 diabetic pregnant women. We retrospectively evaluated 42 subjects, 20 treated with CSII and 22 with multiple dose insulin injections (MDI). The two groups were comparable for age, pre-pregnancy BMI, and primiparous rate, whereas women in the CSII group showed a tendency toward a longer diabetes duration (p = 0.06). Pre-pregnancy diabetic retinopathy and/or nephropathy were present in nine women of CSII and three of MDI. In all women metabolic control improved during pregnancy, without differences between the two groups and at the end of gestation HbA1c was 6.3 +/- 0.6 in CSII and 6.1 +/- 1.1% in MDI. Moreover, there were no differences in weight gain, whereas insulin requirement resulted significantly (p = 0.009) lower in CSII than in MDI. We recorded only one severe hypoglycaemic episode in both groups. No cases of deteriorations of the chronic diabetic complications were observed. The delivery occurred at 36.4 +/- 2.2 weeks; birth weight, the rate of large for gestational age, and the parameters of foetal morbidity were similar in both groups. In conclusions, CSII and MDI are both effective in improving maternal glucose control and have both similar pregnancy outcomes.

A Study Assessing an Injection Port for Administration of Insulin

Objective. To compare an injection port (I-Port), a disposable device through which multiple doses of insulin may be injected, to standard multiple dose insulin administration. Design. Prospective, randomized crossover study. Methods. Seventy-four patients with diabetes being treated with daily injections of insulin were recruited at five clinical sites. The patients were randomly assigned to two of three treatment regimens: 1) standard injection (SI), 2) a single I-Portdevice, or 3) two separate I-Port devices (Dual I-Port) with each treatment regimen lasting for 3 weeks. Participants in the single I-Port regimen injected both regular human or rapid-acting insulin and insulin glargine through the same device,whereas participants in the Dual I-Port regimen injected each type of insulin through two separate devices. Participants were evaluated by measurements of glycosylated albumin and study questionnaires. Results. Participants' glycosylated albumin was not significantly different between SI, single I-Port, and Dual I-Porttreatment regimens (P = 0.99 for SI vs. single I-Port and P = 0.97 for single I-Port vs. Dual I-Port). Fifty of 72 participants (69.4%) reported that the I-Port was useful and helpful in the management of their diabetes. Conclusions. This study supports the utility and efficacy of administering multiple doses of insulin through a single I-Portdevice and concludes that the I-Port is a viable alternative to SI.

Development of a diabetes treatment simulation model: with application to assessing alternative treatment intensification strategies on survival and diabetes‐related complications

The objective of this analysis is to project the long-term impacts on life expectancy and occurrence over 5, 10, and 40 years of microvascular and macrovascular complications of diabetes when using different haemoglobin A1c (HbA1c) thresholds for intensifying treatment of type 2 diabetes. A flexible, discrete-event simulation model has been developed to evaluate alternative treatment strategies based on the United Kingdom Prospective Diabetes Study Outcomes Model. In the present analysis, the model is used to investigate the impact of alternative HbA1c thresholds for treatment intensification ranging from 7.0 to 9.0%. For each intensification strategy, the model is run using 80 simulated patients for each of 1224 patient profiles from the Real-Life Effectiveness and Care Patterns of Diabetes Management study (for a total of 97,920 simulated patients) to project the number of patients who will experience diabetes-related complications over time. The use of lower HbA1c thresholds for intensifying treatment is associated with improved long-term outcomes. When the HbA1c threshold for intensifying therapy from oral treatment to basal insulin (T1) is 7.0% and the threshold for intensifying basal insulin to multiple-dose insulin (T2) is 7.0%, simulated patients spend 54% of their time with HbA1c >7.0%, but 95% of their time with HbA1c >7.0% if T1 and T2 are set to 9.0%. More aggressive or proactive treatment postures are projected to reduce clinical events, including diabetes-related deaths and diabetes-related complications, particularly myocardial infarctions (MIs). When T1 and T2 are set to 7.0%, there are 592 fewer diabetes-related deaths in the first 5 years of the simulation and 3740 fewer deaths over 40 years compared with the results when T1 and T2 are set to 9.0%. These decreases in deaths were also associated with a 0.35 year gain in projected life expectancy. Compared with an aggressive strategy with both T1 and T2 being 7%, 644 more patients are projected to experience at least one episode of MI in the first 5 years if treatment intensification is delayed until HbA1c reaches 9.0%. This number increases over time, reaching 2906 additional patients experiencing at least one MI over a 40-year time period. We report results from a discrete-event simulation model to explore the impact of alternative treatment strategies for patients with type 2 diabetes. Strategies that intensify therapy (in response to rising HbA1c levels) at lower HbA1c thresholds (e.g. 7.0%) are associated with enhanced projected long-term health outcomes.

Comparação entre a bomba de infusão de insulina subcutânea e o esquema de múltiplas doses de insulina em adolescentes com diabetes melito do tipo 1 da rede pública de saúde na abordagem da hipoglicemia grave

We compared the incidence of severe hypoglycemia episodes with therapy with multiple doses of insulin (MDI) and after changing to pump (CSII). 7 T1DM patients with 14 years median and median duration of diabetes of 8 years. We analyzed insulin requirement (U/kg/day), BMI (Kg/m(2)), HbA1c (normal range: 3.5-6.7%) one year before and one year after changing therapy. The severe hypoglycemia episodes decreased from 1.3 to 0 episodes/patient/year; p = 0.00). The insulin requirement decreased from 1.33 +/- 0.26 U/Kg/day to 0.87 +/- 0.17 U/kg/day; p = 0.04 and HbA1c decreased from 8.7 +/- 0.7% to 7.8 +/- 0.9%; p = 0.05. CSII is efficient in decreasing severe hypoglycemia in a subgroup of T1DM using MDI also in Public Health Care System (PHCS) conditions. However, these finding should be reproduced by other Diabetes Care centers and cost studies are necessary to confirm the viability and possibility of this therapy, when necessary, to T1DM patients, which correspond to the majority of these individuals in our country, seeing in the PHCS.

Hypoglycemia, Hypoglycemia Unawareness and Counterregulation in Children and Adolescents with Type 1 Diabetes Mellitus

Three clinical phenomena have been defined in the last decade in patients with diabetes mellitus as a dangerous iatrogenic sequel of hypoglycemia. These are hypoglycemia unawareness, defective glucose counterregulation and a lowered hypoglycemic threshold for hypoglycemic symptoms. Former mild hypoglycemia episodes cause a decrease and a delay in the protective hormonal counterregulatory response and warning symptoms in subsequent episodes, and in the absence of these, risk of severe hypoglycemia increases considerably. It has been demonstrated that when protection is provided against hypoglycemia with strict monitoring programs designed to avoid even mild hypoglycemia episodes, blunted autonomic symptoms and counterregulatory hormonal responses are rectified. Therefore, the best course of action in the treatment of pediatric diabetes mellitus is frequent blood sugar measurements, flexible multiple dose insulin regimens facilitating insulin dose adjustments as required, and a diet. In order to implement this, it is essential to organize an intensive training program with the patient and family, and to provide psychological support and close coordination with the diabetes treatment team.

Multiple-dose insulin injection therapy in patients with type 2 diabetes using a basal-bolus regimen, team management, and nutrition education

We determined the efficacy of basal-bolus insulin therapy delivered through team education and nutrition counseling formanagement of type 2 diabetes in 17 patients treated with a regimen of once-daily insulin glargine and either insulin aspart orlispro three times a day. They received written instructions and specific education about ‘basal-bolus’ insulin administration,use of a ‘forced-titration’ schedule for glargine dose adjustment, and calculation of rapid-acting pre-meal bolus insulin. Theaverage hemoglobin A1c level decreased from 8.7 ± 2.06% to 7.0 ± 1.07%, a significant reduction of 1.7% (p<0.05) over 3months or more. 7 patients (41%) reported improvement in hypoglycemic events. In conclusion, an intensive multidose basalbolusinsulin treatment using self-titration and flexibility through carbohydrate counting confers beneficial effects in patientswith type 2 diabetes, including better glycemic control and reduced hypoglycemia. These results are best achieved throughmulti-disciplinary patient care involving the nurse educator and dietician as part of a diabetes care team. (Int J DiabetesMetab 13:141-146, 2005)

Case Study: Peripheral Neuropathy in Diabetes: Is It Diabetic Neuropathy?

T.T., a 26-year-old woman with type 1 diabetes diagnosed at the age of 14, presented with persistent burning pain in her lower extremities and upper extremity digital paresthesias that made her work as a dental hygienist difficult. Recently, her family had noted that she seemed to be stumbling at times. She reported that neither increased doses of a selective serotonin reuptake inhibitor (SSRI) nor trials of tricyclic antidepressants (phenytoin [Dilantin], carbamazepine [Epitol, Tegretol], or gabapentin [Neurontin]) had relieved her symptoms. T.T. had no known history of diabetic retinopathy or nephropathy. She also denied resting tachycardia, orthostatic lightheadedness, early satiety, early morning nausea, changes in bowel habits, or postprandial sweating. She did note a history of depression, which was treated with counseling and medication. She also noted menstrual irregularity, dysmenorrhea, and premenstrual emotional lability. She had been treated with oral contraceptives in the past, but had discontinued these 6–8 months ago. Her glycemic control had never been optimal despite a multiple-dose insulin program. Her …

Self-Monitoring of Blood Glucose

Many diabetic patients can achieve a normal blood glucose level throughout the day by self-monitoring of blood glucose. Improved control reduces the complications of pregnancy and the development of microvascular disease. Multiple doses of insulin are usually necessary for tight control of blood glucose in patients with insulin-dependent diabetes. In the absence of insulin resistance, 1 u of regular insulin lowers the blood glucose by 30 mg per dL in 90 minutes.

A Comparison of Insulin Pen Use in the United States and the United Kingdom

Insulin pens offer the advantages of simplicity, convenience, and more accurate dosing to insulin-using patients with diabetes. The usefulness of insulin pens is not limited to certain subsets of individuals but extends to all patients who might choose this delivery system. By facilitating acceptance and consistent implementation of multiple-dose insulin regimens, pens hold the potential to promote improved blood glucose control and thus reduce the risk of the chronic complications of diabetes. Both clinical experience and the supporting literature suggest that pen delivery systems are an option that should be routinely offered to all insulin users.